Tag Archives: welfare state

Lonely this Christmas

I love Christmas. But I occasionally find myself in a moment of loneliness in the midst of all the crowds and music and noise. When I see pictures of friends with their newborns, home just in time for Christmas; hear couples conspiring about the perfect present for each other; or catch the refrain of a song and am reminded that no-one is thinking “all I want for Christmas is you” the sparkle loses it’s shine. Being in the ever diminishing demographic of single 30-somethings can be lonely. But these moments are fleeting. I’m soon reminded of how much love surrounds me as my Mum calls to double check when my train is getting in, my brother texts to ask whether vegetarians eat gravy, and my friends email checking who is bringing the Gin at New Year. I know how lucky I am and how full of people my life is, and I was reminded of this on my last day of work before the Christmas holiday.


Ron* was a patient I had previously met in clinic. He had severe COPD and lung cancer for which he’d opted not to have treatment. He was admitted the week before Christmas with breathlessness and we were treating him for an infective exacerbation of COPD. We were fully staffed and the team had the ward under control so there was time to do what I wish we could do more often: sit and chat. Ron was recovering slowly from his exacerbation but still feeling very breathless. He couldn’t walk more than a couple of steps before having to stop and rest. I suggested he would probably need to stay with us until after the weekend, and asked what his plans were for Christmas. He didn’t have any. No family. No friends. He, like so many other invisible members of our communities, would be having Christmas dinner for one. He had, over the years, lost those he cared for and been left alone. I said it was just as well he didn’t have plans as he may need to stay in hospital for Christmas this year. He agreed all too quickly.

I used to think it would be the most awful thing imaginable to be in hospital at Christmas. And for some this is true. But hospitals are bright, warm places, full of caring people. Every member of staff working this Christmas will do their best to spread some cheer, and give out an extra ounce of compassion to those they see. And for those people who have no-one; who might otherwise be alone, ill and afraid; hospital might be the best place to be.   

The NHS is there when no-one else is. It is part of, not only an ideal, but a reality of which we should me immensely proud: the welfare state. As a country we do not value our state services enough. They are not perfect, but they are wonderful.

I worry about the increasing pace of NHS privatisation. Who will be there for those who have no-one in a profit-driven system?

All I want for Christmas is the NHS to survive. Perhaps 2014 is the year to take action to make sure this happens…

Keep our NHS public

Can we find the spirit of ’45 in 2013?

Today marks a defining moment in the history of Britain, but looking around you wouldn’t believe it. Today, April 1st 2013, sees the The Health and Social Care Act (HSCA) come into force.

The death certificate of the NHS, issued by the National Health Action Party

The death certificate of the NHS, issued by the National Health Action Party

Some still believe that those opposed to the HSCA are over-dramatic, reactionary or naive. They will probably dismiss the National Health Action Party as extreme and publicity-seeking as it has issued a death certificate for the NHS, citing the cause of death as the HSCA 2013, with contributing causes including Thatcherism and the failure of New Labour. But it is difficult to see how anything but extreme statements and gestures can capture the attention of the public. Our generation is standing by as the NHS is quietly privatised and I for one am ashamed.

In 1948 the Attlee Labour government founded the NHS “the greatest gift a nation ever gave itself.” Since then it has been gradually eroded and dismantled. The King’s Fund’s infographic depressingly visualises various points of attack by multiple governments, starting with the creation of the internal market in 1989 when Margaret Thatcher signed the paper “Working for patients”. New Labour also have a lot to answer for; their PFI legacy crippling many Trusts today. But no previous government has actually tried to privatise the NHS, knowing that there would be a public outcry. Cameron and Clegg have privatised by stealth; clouding their agenda in a language of ‘choice’ ‘clinician power’ and ‘patient centredness,’ and ensuring that the reform documents were so long and complex that no-one, including most Ministers, understood them. The British media failed to report the warnings of individual doctors, nurses and other healthcare workers, and the demands of traditionally silent bodies such as the Royal College of Physicians to drop the Bill.

Screen Shot 2013-04-01 at 18.33.01

The most worrying aspect of the reforms that come into force today are the Section 75 regulations, which state that all NHS services must be put out to competitive tender. This is not just allowing privatisation, it is mandating it. And all these profit-motivated private firms will be operating under the ‘brand’ of the NHS, so patients may not even know. Until the inevitable problems start to surface and it is too late.

Screen Shot 2013-04-01 at 18.34.44As I watched the welfare state being dismantled around me this week, I went to see Ken Loach’s film The Spirit of ’45 at The Barbican Cinema. It was a poignant reminder of a time full of hope and promise, and was a stark contrast to what I see today. In 1945 there seemed to be a collective vision of a society that could pull together for the benefit of all, with at least some people from all social classes believing that the State was a force for good, and that it had a responsibility to provide and protect the simple things most of us spend life striving for: purpose, dignity in work, family, safety, health, wellbeing, shelter, and comfort. 

Particularly powerful were interviews with doctors and patients who remembered a time before the NHS, when healthcare was only for the rich. In The Spirit of ’45 Dr Jacky Davis and Dr Jonathan Tomlinson, doctors working in the NHS today, talk eloquently about the doctor-patient relationship and about their fears about the future. Marketisation and competition change the relationship of doctors and patients to salesmen and consumers. I am no salesman and never will be.

The day after I saw The Spirit of ’45 I was on call in hospital. I was asked to speak to a patient about her medications before she went home, and quickly scanned through her notes before going to speak to her. She had had a tough few weeks, having been diagnosed with incurable (but treatable) lung cancer – only two weeks from having a chest x-ray revealing an unexpected abnormality to tissue diagnosis and treatment plan. This rapid diagnosis and treatment was an example of what happens every day in the NHS, and is a great example of the efficiency of our healthcare system, but it had left her little time to process the news. She was anxious about her medications prior to discharge so I spent a few minutes clarifying them and reassuring her.

As we ended the conversation she said thanks, and then hugged me tightly. It was nhs logoan unexpected level of physical contact and gratitude for a conversation that could only have lasted ten minutes. But it made me think. She wasn’t really thanking me. She was thanking the NHS: there for her from cradle to grave; at the most difficult time of her life; no questions asked; free at the point of need. Patients in the NHS are taken under the wing of an institution and cared for under an ideology. Today that ideology has suffered a fatal wound. Health is not a commodity, and markets will not make our NHS more efficient, more equitable or of higher quality.

Nye Bevan said “The NHS will last as long as there are folk left with the faith to fight for it”. As Owen Jones says “It is with huge regret that I must say that – however much faith we have – we did not fight to save it. The question now is – do we have enough faith to bring it back to life?”

As I look around the political landscape I fail to be inspired or energised by what I see. Attlee had vision, drive and a belief in the people.

I am looking for the Spirit of ’45 in 2013. Let me know if you find it.

Why I’m against the Health and Social Care Bill

“Are you political, then?” I was asked by a colleague yesterday who had noticed my “doctors say stop the bill” badge fixed proudly to my dress, beside my ID badge and stethoscope. Yes I am. But you don’t have to be “political” to be against this bill. You just have to want an NHS free at the point of need; an NHS in which clinicians are making decisions based solely on your clinical need; an NHS in which you can’t buy your way to the front of the queue; an NHS in which all money goes towards patient care, not shareholders. If you believe in equality and democracy you must make your voice heard, or forever regret it.
So here is a summary of why I, as an NHS doctor, citizen and patient am against the bill. At the end are things you can do to get your voice heard.

1. The government has failed to show that this massive, top-down, reorganisation of the NHS is “vital” as it claims. The NHS needs reform. No-one doubts this. But this bill is not the answer. There is no clear vision of what is trying to be achieved. I have not heard a single politician articulate the aims of the bill. In fact the changes that politicians, patients and doctors agree would be beneficial, including shifting decision-making powers to clinicians and streamlining patient pathways do not require legislation, and can be achieved without wholesale structural change. 

2. The government has no mandate for the destruction of the founding principles of the NHS. The changes proposed in the bill were not in the Conservative or Liberal Democrat manifesto. They were not in the coalition agreement. There has been no vote. The government has already started implementing parts of the bill before any House of Lords approval or Royal Assent. This premature and rapid implementation is already causing chaos on the ground, destabilising services. The government has also blocked demands to publish the risk register, and is ignoring the ruling of the information rights tribunal to publish it, underlining its total lack of respect for public opinion and democracy. The last time similar actions were taken was when there was a public demand for release of the legal advice the Blair government received about the legality of military action in Iraq, prior to the start of the conflict in 2003. We all remember how that turned out. The government has also ignored the e-petition and refused to hold a debate, despite gaining far more than the required 100,000 signatures. Pushing forward with the bill is undemocratic, autocratic and wrong.

3. Privatisation will increase under this bill. This is bad for patients. The record of private company involvement in the NHS is not good. PFI may have created a few sparkly hospitals but taxpayers will continue to pay extortionate amounts     for this privilege for years. Private companies only want to undertake simple, straightforward procedures in patients who are low risk. Not only does this leave out many older people with multiple co-morbidities, but when any patient has a procedure done privately, complications are dealt with in the NHS. The PIP implant disaster exposed the fact that private companies cannot be held accountable by the government; have no obligation to collect or supply accurate information about what they are doing; fiercely resist any duty of care to patients; and are more concerned with cost than quality. Look forward to more of this, not just in relation to cosmetic surgery. Private companies want all the profit, none of the risk and this bill hands it to them.

4. Those expected to implement the bill do not want it. The coalition have attempted to sell the bill to the public on the basis of clinician-led commissioning, giving power back to clinicians. Well, clinicians have made their opinion clear. Name a professional body and you can find a statement opposing the bill. Every day I am thankful that I am free to make decisions with patients based on clinical need, not cost. In all but a few specialist circumstances, such as new and expensive cancer drugs, cost never enters clinical discussions in the NHS. And we want it to stay that way. GPs, the clinicians who supposedly have the most to gain have made it clear that they do not have the time or skills required to deliver commissioning in the proposed model. They are first and foremost doctors, not managers.  Therefore the CCGs will outsource to private companies. More public money in the hands of shareholders, rather than patients.

Reorganisations and increased bureaucracy will cost the taxpayer heavily, at a time of austerity and cuts.

5. The bill will introduce more bureaucracy, which will cost, and will distract from care-giving. It will replace three layers of management in the NHS with at least six new ones. Many of the staff in primary care trusts have already left, returning to work for the commissioning groups and commissioning support services, often as consultants on a higher salary. This bureaucracy will not only slow down innovation and change, but will be hugely expensive. Management costs in the NHS are about 5% of the total budget. In the healthcare system in the US they are above 25%. It is a fallacy that markets drive efficiency. If the bill is passed, management consultants such as McKinsey and KPMG will make millions from the NHS budget “advising” clients on both sides of the purchaser/provider split, with additional contracts “advising” government and health regulators how to cope with the tangled web of contracts the new system would create.

Nye Bevan, founder of the NHS said “the NHS will survive as long as there are people left with the faith to fight for it”. I have faith. Do you?

Write to your MPadopt a peerwrite to your local paper, tell everyone you know, twitter your thoughts with #SaveOurNHS #dropthebill, directly tweet MPS eg @nick_clegg, @SWilliamsMP, @VinceCable #LDConf #lostvotes.

Other people have said all this and more, much more eloquently then me. Here are a few examples:

1. Clive Peedell, Clinical Oncologist and campaigner speaking at the Save Our NHS Rally

2. FalseEconomy.org.uk’s assessment of the effects of the bill – 5 facts

3. The Lancet’s summary, highlighting the failure of the bill to safeguard the core principles of universal care and the duties of the Secretary of State to uphold those principles. “The duty on the Secretary of State to provide or secure provision in accordance with the founding legislation of the 1946 Act must be restored if England is to have a national health service.” 

4. A patient who has found “gratitude, if not joy, in illness because we have a National Health Service, built on care.”

5. David Nicholl, a neurologist and human rights activist, explains why the NHS bill is beyond repair

6. Kailash Chand, a GP and the originator of the “Drop the health bill” e-petition

7. Analysis of Health and Social Care Bill published in BMJ, which concludes that it introduces a legal basis for charging and providing fewer health services (summary and link to full text)

What is the NHS for?

At a party this week I got talking to a friend of a friend who quickly discovered I was a doctor. The conversation changed from which tube lines were running and who had made the delicious chocolate brownies, to the NHS: specifically its failings. I become, not for the first time, an embodiment not only of the medical profession, but of the entire health and social care system. I was charged with defending the lack of care shown by GPs, the apparent willingness of doctors to prescribe pills for anything and everything but never to listen, the lack of a nutritional perspective from NHS practitioners and the poor funding of mental health services.

The NHS is not perfect. I have heard many stories from dissatisfied individuals, and wouldn’t for a moment dismiss their grievances. I have even been known on occasion to spend an entire dinner party lambasting its’ deficiencies. But conversations like this make me wonder about the expectations of the public of this institution of which I am extremely proud. What do they think the NHS is for?

Sir William Beveridge, founder of the welfare state

When Sir William Beveridge created the welfare state, and Nye Bevan announced the foundation of the NHS in 1948 it was with the  expectation that the costs would be recouped by the beneficial effects on the health of the nation. But the NHS is a victim of its own success, and people now live longer with many more chronic diseases and health needs. Technological advances have exponentially expanded what we can offer with an associated financial burden. The treatment for a heart attack used to be an aspirin and bed-rest, and is now emergency primary percutaneous coronary intervention in state of the art angiography suites and coronary care units. The concept of health itself has also changed from the simple lack of disease to “a state of complete physical, mental, and social well-being”. I don’t think I know anyone who would claim to have woken up in the last week feeling “healthy” if that is the definition.

Many of the problems the NHS faces are not new. In a Panorama program of 1967 practicing physicians identified frustrations that would be familiar to today’s doctors: poor planning of location and design of hospitals with no flexibility for future changes; patient delays awaiting specialist opinions and investigations; and discharge delays awaiting social care placement. Many of these problems are to do with funding, system structures, political priorities, and the interface between health and social care. And that’s without even looking at the wider social determinants of health and their impact on effective healthcare provision. The 1967 physicians also identified the difficulties of financing this vast system and the need for efficiency, with some arguing we spent too much and others arguing we spent too little on healthcare. The NHS is often compared to the US system, with its’ private focus and business ethos. Interestingly in 2009 healthcare spending as a percentage of GDP was higher in the USA (17.4%), than France (11.8%), Germany (11.6%) and the UK (9.8%). The NHS is not expensive and inefficient as it is often characterised and free markets are no panacea – just one of many reasons why the Health and Social Care Bill is not the answer. Collaboration not competition is a growing mantra amongst my colleagues.

Nye Bevan, Minister for Health. "...despite our financial and economic anxieties, we are still able to do the most civilised thing in the world: put the welfare of the sick in front of every other consideration.”

So what should the NHS be for? Should it have a limited remit, focused on high-quality but basic healthcare provision? Does this imply newer drugs and technologies would be unavailable to those without additional money to pay a “top-up” fee? Are we happy with such an abandonment of equity and equality? What is defined as basic healthcare, and what would fall outside this remit? Who would decide? Where does public health and prevention fit into the system? Or should the NHS strive to compete with other, privately-funded systems, and provide up to the minute technologies and breakthroughs to all, whatever the cost? Will the electorate agree to paying higher taxes to achieve this? Should it be the NHS’s responsibility to provide complementary therapies if this is what the public demands? Should doctors be more qualified in giving nutritional advice, despite the lack of validated evidence of benefit of nutritional interventions for many conditions? Where do we draw the line between health and social care? Should the NHS’s remit extend to mechanisms for redistributing wealth since inequality is at the heart of so many problems?

Good healthcare should be available to all, regardless of wealth. This principle must never be lost. The NHS employs more than 1.7 million people, and treats 3 million people every week, for free at the point of need. It is the world’s largest public funded health service and one of the most efficient, egalitarian and comprehensive. The remit of the NHS grows daily: stretching from cradle to grave; prevention to cure; physical to psychological, but it can’t do everything. So next time you encounter a doctor at a party feel free to express your grievances, highlight inefficiencies and debate the politics, but don’t expect them to be anything but immeasurably proud of the NHS’s founders and those that work within it today.